Question bank Flashcards
Normal range for albumin
3.5-5.5g/dL
35-55g/L
To find out about drug interactions choose the SINGLE most appropriate database from the list: -
- Cochrane database
- Medline
- National institute for clinical excellence (NICE) website
- British National Formulary
- BMA website
- Evidence-based medicine website
- BMJ website
British National Formulary
The BNF will tell you about indications and contraindications for drugs
50 yr old housewife presents with parities and jaundice with pale stools, dark urine and steatorrhoea, pigmentation and xanthelasma. Examination reveals splenomegaly. Anti-mitochondrial antibodies are present
Primary biliary cirrhosis
PBC is chronic where intrahepatic small bile ducts are progressively damaged (then lost) occurring on background of portal tract inflammation. Fibrosis develops leading to cirrhosis. believed to be autoimmune (most have AMA)
65 year old ex-smoker is deeply jaundiced. He has epigastric pain radiating to his back. A dilated gall bladder is palpable and there is hepatomegaly. He has lost about 5kg in weight
Carcinoma of the pancreas
Head of pancreas cancer presents with painless obstructive jaundice and weight loss and presents late. There is epigastric pain here which is possible. Whipple’s procedure or Traverso-Longmire procedure (pancreaticoduodenectomy)only cure. tumour marker for pancreatic cancer is CA19-9 which is useful in pre-op staging
A 23 year old male was upset England lost a penalty shoot-out and decided to kick a wall in a construction site on the way home. The wall fell on him and he was crushed. It took paramedics a long time to retrieve him from the rubble. His leg is swollen and tender. Urine specimen has a dark red appearance.
Rhabdomyolysis
This is a crush injury that has caused myocyte lysis – rhabdomyolysis. The diagnosis would be confirmed by raised CK. The swelling and pain in his leg muscle is a further give away. The dark urine here is caused by urinary myoglobin. The long time it took for him to be retrieved is also an indication of this diagnosis. The mainstay of treatment is with fluid hydration.
A 22 year old man comes to see you on his return from a holiday in Spain. He has a 3-4 day history of fever, malaise, nausea, vomiting and abdominal discomfort. He is noticeably jaundiced with dark urine and pale stools. there is also tender hepatomegaly on examination. he wonders if this is related to his meal of shellfish from a street vendor
Hepatitis
Likely to be hep A which is primarily transmitted via faecal-oral route. after virus is consumed and absorbed it replicated in liver and is excreted in bile. transmission precedes symptoms by 2 weeks and patients are non-infectious 1 week after onset of jaundice. risk factors include living in endemic area, contact with infected person, homosexual sex or known food-borne outbreak, SHELLFISH
A 6 year old Black boy presents with mild jaundice and some pain and swelling of his fingers. O/E you note splenomegaly
Sickle Cell anaemia
Africans have higher incidence of SC anaemia. here there is bone pain with dactylics, consistent with hand-foot syndrome which can be what young infants and kids present with. jaundice is due to haemolysis
A 35-year-old overweight woman complained of severe abdominal pain and vomiting. She had had a previous attack when on holiday and had had to be flown home as a medical emergency. She looks jaundiced and in distress.
Pancreatitis
A 47-year-old male policeman was brought to A&E having become SOB suddenly. He now complains of palpitations, which he has never experienced before. Heart sounds are irregular but no murmurs are audible. He is a diabetic with hypertension.
Atrial Fibrillation
Match the cause of hypotension to the following case history:
76-year-old woman was admitted with confusion. She had been increasingly unable to care for herself. On admission, she was found to have cool peripheries and her blood pressure was 100/70. Blood results showed plasma urea 25 mmol/L and plasma creatinine 120 μmol/L.
Volume depletion
Volume depletion is a reduction in ECF volume due to salt and fluid losses which exceed intake. Causes include vomiting, bleeding, diarrhoea, diuresis and third space losses. Symptoms do not occur until large losses have alrady occured. Cool peripheries are a sign of peripheral shut down. Confusion may reflect poor cerebral flow or uraemia.Volume depletion has led to the low BP. Other symptoms include postural hypotension and tachycardia, weight loss and signs of shock. Serum urea and creatinine is elevated (you need to eyeball the patient when looking at creatinine – a very big body builder will have a much higher creatinine), indicating poor renal blood flow. This patient needs IV saline fluid replacement.
Match the cause of hypotension to the following case history:
22-year-old man presented with vomiting. He had not been feeling himself for some weeks. On examination, the skin creases of his hands were dark. Blood results showed plasma urea 8.5mmol/L, sodium 121 mmol/L and potassium 5.1 mmol/L.
Hypoadrenalism
Hyperpigmentation in the palmar creases points towards Addison’s disease. Hyperpigmentation due to excess ACTH production can be mucosal or cutaneous and is more pronounced in the palms, knuckles and around scars. MSH is a byproduct of the production of ACTH from the cleavage of POMC. Sodium is low and potassium elevated. Vomiting is present in 75% of patients and nausea is a common finding. Additionally, postural hypotension may be present. The presence of other autoimmune diseases is also a risk factor for the development of Addison’s.
Match the cause of hypotension to the following case history:
45-year-old man presented with severe chest pain radiating down his left arm. He was pale, cold and sweaty. BP was 80/50 mmHg, pulse rate was 100 and regular. JVP was raised by 3cm and auscultation of his chest revealed basal creps. Over the next few hours, he became progressively short of breath despite being given IV diuretics. Chest x-ray showed signs of pulmonary congestion
Cardiogenic shock
Cardiogenic shock is pump dysfunction. This may occur, like in this case, after MI (shock complicates just under 10% of MIs) or may be due to cardiomyopathy, valve dysfunction or arrhythmias. This cause of shock in this patient is obviously apparent. Clinical signs of shock include stress responses of tachycardia and tachypnoea, hypotension (
Match the cause of hypotension to the following case history:
67-year-old man was observed to be very drowsy 12 hours after an aortic aneurysm repair. There had been considerable blood loss and he had been given 4 units of blood during surgery. He had been written up for pethidine 50-100 mg 3 hourly postoperatively and had had 3 doses. BP had been 150/80 post-op and was now 100/60 with a pulse rate of 75/min. O2 saturation was low at 85%.
Drug induced
Opioid OD symptoms include CNS depression (drowsiness, sleepiness), respiratory depression and relative bradycardia. This patient needs ventilation prior to the administration of naloxone, titrated to patient response.
To find systematic reviews of literature choose the SINGLE most appropriate database from the list: -
- Cochrane database
- Medline
- National institute for clinical excellence (NICE) website
- British National Formulary
- BMA website
- Evidence-based medicine website
- BMJ website
Cochrane database
The Cochrane database was established by the NHS with the aim of being a place to review existing literature on a subject matter.
To find original research articles choose the SINGLE most appropriate database from the list: -
- Cochrane database
- Medline
- National institute for clinical excellence (NICE) website
- British National Formulary
- BMA website
- Evidence-based medicine website
- BMJ website
Medline
Medline, or pubmed, is run by the US Government and will help you search through many journals with keywords to look for new and older research on a matter
To find disease management guidelines choose the SINGLE most appropriate database from the list: -
- Cochrane database
- Medline
- National institute for clinical excellence (NICE) website
- British National Formulary
- BMA website
- Evidence-based medicine website
- BMJ website
National institute for clinical excellence (NICE) website
In the UK, NICE currently analyses the medical and cost-effectiveness of various treatment options and publishes guidelines based upon this
To find out about drug use in the lactating mother choose the SINGLE most appropriate database from the list: -
- Cochrane database
- Medline
- National institute for clinical excellence (NICE) website
- British National Formulary
- BMA website
- Evidence-based medicine website
- BMJ website
British National Formulary
The BNF will tell you about indications and contraindications for drugs
25yr old man presents to you with an incidental finding of raised bilirubin (31umol). no other signs of liver disease are present. Further investigations show raised unconjugated bilirubin. When asked he tells you that other family members have suffered jaundice
Gilbert’s Syndrome
occur in asymptomatic patients as incidental finding/mild jaundice in adolescence. high unconj BR other liver tests normal. blood smear normal, normal reticulocyte count, normal Hb showing not due to haemolysis. no treatment needed, condition due to low UDPGT activity causing low conjugation of unconj bilirubin so high levels. positive FH common, as autosomal recessive
Choose the SINGLE test from the list that would be of most help in establishing a diagnosis of aortic dissection.
A. CT head B. MRI head C. CT chest, abdomen and pelvis D. Trans-thoracic echocardiography E. Ventilation-perfusion scan F. D-dimer G. Duplex ultrasound H. Upper GI endoscopy I. Barium enema J. Renal function tests K. Barium swallow
CT chest, abdomen and pelvis
Dissecting aneurysms are either type A, which involves the ascending aorta, or type B. Type A dissections require urgent surgery whereas type B can be managed medically if it is not complicated by end organ ischaemia. A CT scan is indicated as soon as a diagnosis of aortic dissection is suspected and should be from the chest to the pelvis to see the full extent of the dissecting aneurysm. What you will see is the intimal flap. MRI is more sensitive and specific but is more difficult to obtain acutely.
Choose the SINGLE test from the list that would be of most help in establishing a diagnosis of pituitary tumour.
A. CT head B. MRI head C. CT chest, abdomen and pelvis D. Trans-thoracic echocardiography E. Ventilation-perfusion scan F. D-dimer G. Duplex ultrasound H. Upper GI endoscopy I. Barium enema J. Renal function tests K. Barium swallow
MRI head
Pituitary MRI is preferred over CT and you will be able to see if the tumour has invaded, for example, the sphenoid sinus and cavernous sinuses or any compression of the optic chiasma. MRI is contra-indictaed in some cases such as those with a permanent pacemaker or those with ESRF on dialysis – in which case you would perform a CT. Both are done with contrast enhancement. A sellar mass will be seen.
Choose the SINGLE test from the list that would be of most help in establishing a diagnosis of renal artery stenosis.
A. CT head B. MRI head C. CT chest, abdomen and pelvis D. Trans-thoracic echocardiography E. Ventilation-perfusion scan F. D-dimer G. Duplex ultrasound H. Upper GI endoscopy I. Barium enema J. Renal function tests K. Barium swallow
Duplex ultrasound
Renal artery stenosis is basically narrowing of the renal artery. There may not be any clinical consequences of this – just because someone’s renal arteries are narrowed does not mean they are suffering worsening kidney function, although this may be the case, especially after blockade of the renin-angiotensin system, and patients may have difficult to control and accelerated hypertension. A definitive diagnosis is made on imaging, where there is some controversy on what is most appropriate to use. USS is safe and non-invasive but the sensitivity and specificity is low. CT/MR angiography has the risk of contrast nephropathy and nephrogenic systemic fibrosis. Conventional angiography (the best test available) has the risk of bleeding and emboli as well as contrast related risks already mentioned.
Generally, the recommendation is to start with renal duplex ultrasound. This would not be an unreasonable approach. This can be followed by further tests. Although, in some centres in the country, the first line is CT or MR angiography and duplex USS is only done if there is a contra-indication to CT/MR angiography. However, the only reasonable option on this list is duplex USS.
A 45 year old man presents with sudden onset epigastric pain, constant in nature. He has had several previous episodes. He drinks half a bottle of whiskey per day. what does he have?
Acute pancreatitis
Choose the SINGLE test from the list that would be of most help in establishing a diagnosis of pulmonary embolism.
A. CT head B. MRI head C. CT chest, abdomen and pelvis D. Trans-thoracic echocardiography E. Ventilation-perfusion scan F. D-dimer G. Duplex ultrasound H. Upper GI endoscopy I. Barium enema J. Renal function tests K. Barium swallow
Ventilation-perfusion scan
The first line recommended initial imaging test is a CT chest to directly visualise the thrombus in a pulmonary artery, which would show as a filling defect. However this option is not given in this list and the test to pick here is a V/Q scan, which offers a similarly high level of sensitivity and specificity. In a PE the area affected will be ventilated but not perfused.
A 58 year old man who is recently diagnosed with lung cancer has started chemotherapy and radiotherapy. He complains of a fever, weight loss and fatigue. There are swollen lymph nodes and tetany. Serum potassium is elevated and calcium is low.
Tumour lysis syndrome
There is recent diagnosis of malignancy here combined with the recent start of both chemotherapy and radiotherapy. This is tumour lysis syndrome which encompasses metabolic and electrolyte abnormalities, like hyperkalaemia, occuring after cytotoxic treatment in a patient with cancer. There is excessive cell lysis and the release of intracellular contents into the bloodstream leads to elevated levels of serum urate, potassium, phosphate and a reduction in calcium level.
A 72 year old woman is being treated for a diabetic foot ulcer and is afraid she may need an amputation. Serum potassium today is markedly elevated. Results over the past week have been normal. You find out the 2nd year medical student had some difficulty drawing the blood.
Pseudohyperkalaemia
This is pseudohyperkalaemia caused by haemolysis of the sample. The medical student who has had some difficulty drawing the blood has haemolysed the sample. Potassium in serum will in this case exceed the plasma value by >0.5 mmol/L and the pink tinge when centrifuging the sample will also give this away.
A 28 year old male presents with increased skin pigmentation, vitiligo, postural hypotension and raised potassium. Urine potassium is low. He has also lost some weight.
Addison’s disease
Hyperpigmentation is due to excess ACTH production and can be mucosal or cutaneous and is more pronounced in the palms, knuckles and around scars. MSH is a byproduct of the production of ACTH from the cleavage of POMC. Sodium is low and potassium elevated in this condition. Additionally, postural hypotension may be present. The presence of other autoimmune diseases is a risk factor for the development of Addison’s, such as this man’s vitiligo. Diagnosis of Addison’s can be made on an ACTH stimulation test (synacthen test) whereby serum cortisol remains low despite the administration of synthetic ACTH. In an emergency, treatment should not be delayed by diagnostic testing.
A 16 year old diabetic has been trying to lose weight. She presents at with a vomiting, postural hypotension and abdominal pain. She insists she has been taking her insulin regularly and does not use illicit drugs. Serum potassium is elevated.
DKA
Hyperpigmentation is due to excess ACTH production and can be mucosal or cutaneous and is more pronounced in the palms, knuckles and around scars. MSH is a byproduct of the production of ACTH from the cleavage of POMC. Sodium is low and potassium elevated in this condition. Additionally, postural hypotension may be present. The presence of other autoimmune diseases is a risk factor for the development of Addison’s, such as this man’s vitiligo. Diagnosis of Addison’s can be made on an ACTH stimulation test (synacthen test) whereby serum cortisol remains low despite the administration of synthetic ACTH. In an emergency, treatment should not be delayed by diagnostic testing.
A 65-year-old man with a six-month history of ischaemic heart disease on Aspirin presents with a one-month history of epigastric pain and two days of dark stools. He has vomited a ‘cupful’ of fresh blood this morning.
Choose the SINGLE most appropriate diagnostic investigation from the list: -
A. H.pylori breath test B. Colonoscopy C. Chest x-ray D. Liver biopsy E. Full blood count F. CT scan abdomen G. Upper GI endoscopy H. Liver function test I. Barium swallow J. Upper GI endoscopy K. Clotting profile
Upper GI endoscopy
NSAID use is a key risk factor for a peptic ulcer. Other key risks include H. pylori infection, smoking and FH of PUD. Zollinger-Ellison syndrome should be considered if there are multiple ulcers or ulcers refractory to treatment. The epigastric pain and symptoms of dark stools are consistent with a bleeding peptic ulcer. The most specific and sensitive test is an upper GI endoscopy which also allows management of the bleed. A biopsy may also be done to rule out malignant transformation. Gastric ulcers require a compulsory biopsy but duodenal ulcers rarely undergo malignant change. Management here can be aimed at discontinuing NSAIDs which are the cause in this case.
A 32-year-old man attends your surgery saying he brought up blood every morning for the last week. He is unsure whether he is vomiting or coughing it up. His haemoglobin (done yesterday) is 14 g/dL.
Choose the SINGLE most appropriate diagnostic investigation from the list: -
A. H.pylori breath test B. Colonoscopy C. Chest x-ray D. Liver biopsy E. Full blood count F. CT scan abdomen G. Upper GI endoscopy H. Liver function test I. Barium swallow J. Upper GI endoscopy K. Clotting profile
Chest x-ray
The blood being brought up here occurs at a fixed time period every day and he is not anaemic. This makes you suspect a respiratory cause of his haemoptysis such as pneumonia – particularly TB, cancer, vasculitis like Wegener’s, bronchiectasis and bronchitis.
A 55- year-old lady on Warfarin for recurrent pulmonary emboli presents having vomited a small amount of blood that morning. She has been on antibiotics for a presumed chest infection for the last week.
Choose the SINGLE most appropriate diagnostic investigation from the list: -
A. H.pylori breath test B. Colonoscopy C. Chest x-ray D. Liver biopsy E. Full blood count F. CT scan abdomen G. Upper GI endoscopy H. Liver function test I. Barium swallow J. Upper GI endoscopy K. Clotting profile
Clotting profile
This woman is on prophylactic warfarin anticoagulation. There is an interaction here with the antibiotics this woman is taking which has resulting in enhanced anticoagulation effects of warfarin, causing her to bring up the blood. Cepahalosporins, chloramphenicol, ciprofloxacin, clarithryomycin, erythromycin and metronidazole are all examples which increase the effect of warfarin. Any P450 inducer will have this effect as warfarin is a drug metabolised by cytochrome P450 enzymes. Antibiotics can also upset the gut flora which reduces vitamin K levels.
A 45-year-old man with a history of occupational exposure to dust in the building and demolition industry presents with SOB. On examination clubbing and signs of peripheral effusion.
Most appropriate investigation?
A. Bronchoscopy B. Chest x-ray C. Stool culture D. Lung function tests E. Abdominal ultrasound scan F. Colonoscopy G. Echocardiogram H. Sputum culture
Chest x-ray
Idiopathic pulmonary fibrosis (previously known as Cryptogenic fibrosing alveolitis) progresses over several years and is characterised by pulmonary scar tissue formation and dyspnoea. Patients complain of a non-productive cough and typically reproducible and predictable SOB on exertion. This man’s work means he comes into contact with small organic or inorganic dust particles which is thought to be implicated in the cascade of events leading to IPF. Another risk factor is cigarette smoking which significantly increases the risk of IPF. The mean age of diagnosis is 60-70. CXR here will show reticular opacities. A high resolution CT scan can also be done if it was an option on this list.
A 72-year-old man, admitted to hospital with a single large haematemesis and continuing abdominal pain. Upper and lower GI endoscopy were reported as ‘unremarkable’
Choose the SINGLE most appropriate diagnostic investigation from the list: -
A. H.pylori breath test B. Colonoscopy C. Chest x-ray D. Liver biopsy E. Full blood count F. CT scan abdomen G. Upper GI endoscopy H. Liver function test I. Barium swallow J. Upper GI endoscopy K. Clotting profile
CT scan abdomen
The cause here could be an aortoenteric fistula or AVM. You have to assume with endoscopy here that upper and lower GI endoscopy were unremarkable. The next step on this list would be a CT scan with contrast to detect the GI bleed. You would expect to see the active bleeding with contrast leaking into the bowel lumen.
A 46-year-old woman complains of right loin pain. Her mother had been on dialysis in Australia for 10 years. Plasma creatinine 180 μmol/l. No abnormalities were detected on urinalysis. Most appropriate investigation: - Renal ultrasound CVP measurement Renal biopsy Plasma electrophoretic strip
Renal ultrasound
A dominantly inherited cause of renal failure is likely to be polycystic kidney disease which is best noted on ultrasound
A 28-year-old woman with a carcinoma of the cervix was admitted with plasma creatinine of 250μmol/l. BP was 130/80. Urinalysis was negative. Most appropriate investigation: - Renal ultrasound CVP measurement Renal biopsy Plasma electrophoretic strip
Renal ultrasound
A patient with cervical carcinoma is at risk of ureteric obstruction and then hydronephrosis. Again ultrasound is the test of choice
A 32-year-old man presents with oedema. Plasma creatinine 150 μmol/l, urea 15 mmol/l, albumin 15 g/l. Urine protein excretion 8.5 gm/24 hour. Routine immunescreen (antinuclear antibody, complement levels, CRP) is normal. Most appropriate investigation: - •Renal ultrasound •CVP measurement •Renal biopsy •Plasma electrophoretic strip •Intravenous pyelogram •Renal arteriogram
Renal biopsy
When the cause of renal failure might be nephritis (as in nephrotic syndrome) a renal biopsy will be needed to make the diagnosis. Occasionally this is urgent, so that potent immunosuppresives can be administered
A 76-year-old man presents with lethargy and back pain. Plasma creatinine 220 μmol/l, urea 18 mmol/l, calcium 2.9 mmol/l (2.2 – 2.6), albumin 29 g/l. Urine protein excretion 1.5 gm/24 hours Most appropriate investigation: - •Renal ultrasound •CVP measurement •Renal biopsy •Plasma electrophoretic strip •Intravenous pyelogram •Renal arteriogram
Plasma electrophoretic strip
Lethargy, back pain, hypercalcaemia and renal impairment all point towards multiple myeloma.
Renal impairment in myeloma results from a combination of factors: deposition of light chains, hypercalcaemia, hyperuricaemia and (rarely) in patients who have had the disease for some time, deposition of amyloid. Serum protein electrophoresis characteristically shows a monoclonal band
A fit 28 year old man comes for an insurance medical and is found to have microscopic haematuria and, on abdominal examination, is found to have 2 large masses about 20cms by 12cms in each flank. Which investigation should be performed?
Abdominal ultrasound
This sounds like ADPKD. There may be a FH of PKD or ESRF or cerebrovascular events (intracranial berry aneurysms in the circle of Willis and SAH). Patients may have haematuria, palpable kidneys and symptoms of a UTI. Hypertension and flank pain are also commonly seen. Hepatosplenomegaly may also be found. A renal ultrasound is the first test to order when the diagnosis is suspected. If the ultrasound is equivocal, a CT scan can be done of the abdomen and pelvis.
A 25-year-old woman comes back from holiday complaining of a two day history of frequency and dysuria. On dipsticking the urine you find red cells, leukocytes and protein. Which investigation should be performed?
MSU: microscopy and culture
This young woman has presented with a UTI (dysuria, frequency, haematuria). Sexual activity the strongest risk factor for UTIs in women and she’s just come back from ‘holiday’. It is diagnosed with a urine dipstick (already done), and microscopic analysis for bacteria, WBC and RBC and urine culture and antibiotic sensitivities. Antibiotic selection should be based on local guidelines or known sensitivities. Uncomplicated UTIs with no known antibiotic resistance can be treated with co-trimoxazole or nitrofurantoin. If there is resistance, a quinolone can be considered such as ciprofloxacin.
A 75-year-old man who presents with frank, painless haematuria. He tells you that 3 years ago he had a similar episode and was diagnosed as having ‘warts in the bladder’. After treatment, he moved and was lost to follow-up but had been symptom free since then. Which investigation should be performed?
Cystoscopy
“Warts in the bladder” is the way of some sneaky urologist avoiding telling this man he had cancer. He was treated, and like all cancer patients, was followed up. Unfortunately, this sounds like a recurrence. Gross haematuria is the primary symptom of bladder cancer. Cystoscopy and urinary cytology are key in diagnosis. Low grade tumours are papillary and easy to see on cystoscopy whereas high grade tumours and carcinoma in situ are often difficult to visualise. Resection provides diagnosis and primary treatment in one step.
A 45-year-old man wakes in the night with severe pain in his right flank radiating round to the front and into his groin. He can’t get comfortable, but on examination his abdomen is soft with no masses. His urine shows a trace of blood but no other abnormality. Which investigation should be performed?
Helical CT
This patient has renal colic which classically presents with severe flank pain radiating to the groin. Microscopic haematuria is present in up to 90% of cases. Up to 85% of stones are visible on a plain KUB although urate stones are radiolucent. If the stone is radio-opaque, calcification will be seen within the urinary tract. In pregnancy, a renal USS is first line. The IVP has now been replaced by the CT scan which is the new diagnostic standard. A non-contrast helical (or spiral) CT is preferred due to high sensitivity and specificity and acurately determines presence, site and size of stones. Stones are analysed after they are extracted or when they are expelled to check their composition. It is worth noting that in all females of child bearing age, a urine pregnancy test is necessary to exclude an ectopic pregnancy.
An 80 year old man presents with severely painful feet with mottled and purple toes with black areas. He tells you that he has also had constant severe back pain for a few days. Most appropriate investigation? A. Blood sugar B. Arteriogram C. Cold provocation test D. Full blood count E. CT scan F. Venous duplex scan G. Blood cultures H. Lumbar puncture I. Anti-neutrophil cytoplasmic antibody
CT scan
This patient has a dissecting aortic aneurysm which can be diagnosed with a CT scan showing the presence of an intimal flap. The CT scan should include chest, abdomen and pelvis to visualise the extent of the aneurysm. Dissecting aneurysms are either type A, which involves the ascending aorta, or type B. Type A dissections require urgent surgery whereas type B can be managed medically if it is not complicated by end organ ischaemia. The aortic dissection has led to a cholesterol embolism. This can be diagnosed histopathologically with the finding of cholesterol crystals. The phenomenon where cholesterol is released from an atherosclerotic plaque is called ‘trash foot’. A highly technical medical term. This results in the mottled appearance of distal embolism associated with livedo reticularis. You can search the internet for some case reports of this phenomenon.
A 35 year old woman arrives on a plane from Melbourne with a swollen right leg. A few days later her leg is even more swollen and her toes have gone black Most appropriate investigation? A. Blood sugar B. Arteriogram C. Cold provocation test D. Full blood count E. CT scan F. Venous duplex scan G. Blood cultures H. Lumbar puncture I. Anti-neutrophil cytoplasmic antibody
Venous duplex scan
This patient has a DVT. Other risk factors include recent major surgery, active malignancy, pregnancy and malignancy. A Wells score is determined in all patients with a suspected DVT with the condition being likely if the score is 2 or greater. The most definitive test is venography but it is invasive. Compression USS of the proximal deep venous system is preferred but Doppler venous flow testing can be used if other tests are unavailable and will demonstrate low flow in affected veins. This requires a trained technician. Anticoagulation is the mainstay of treatment with unfractionated heparin, a LMWH or an anti FXa agent such as fondaparinux
A 25-year-old university student presents with high fevers. He has a petechial rash, black areas on his digits and a blood pressure of 70/50. Most appropriate investigation? A. Blood sugar B. Arteriogram C. Cold provocation test D. Full blood count E. CT scan F. Venous duplex scan G. Blood cultures H. Lumbar puncture I. Anti-neutrophil cytoplasmic antibody
Blood cultures
This patient has sepsis. Sepsis is the presence of SIRS with a likely infectious cause. This patient’s profound arterial hypotension means he has severe sepsis (dysfunction of one or more organ systems). The patient being a young university student most likely has meningitis even though symptoms of headache, photophobia and neck stiffness are not mentioned. Hence, a LP would be performed but it is not the 1st test to order in a patient who presents with sepsis.
It is important in the first instance to obtain a blood culture immediately, and preferably before antibiotics are started. If this is bacterial meningitis, you would expect to see a raised WCC on the LP with elevated protein, normal/reduced glucose and predominantly neutrophils in the white cell differential. Early blood cultures allows you to either broaden your empirical antibiotic spectrum or narrow it in those with sensitive organisms. It is worth noting that in sepsis, the patient may have a low temperature
A 32 year old woman at 34 weeks gestation presents with acute RUQ pain and a frontal headache. There is oliguria and increasing oedema as well as proteinuria of 3+ on urinalysis. Creatinine is elevated. The doctor starts her on labetalol
Pre-eclampsia - syndrome characterised by new onset hypertension, and proteinuria in pregnant women after 20 weeks gestation. The only definitive treatment is to deliver the placenta.
A 55 year old woman presents with painful joints, a purpuric rash on her arms and legs. Systems review reveals heamoptysis and ear pain. On examination you find black patches on her toes. Most appropriate investigation? A. Blood sugar B. Arteriogram C. Cold provocation test D. Full blood count E. CT scan F. Venous duplex scan G. Blood cultures H. Lumbar puncture I. Anti-neutrophil cytoplasmic antibody
Anti-neutrophil cytoplasmic antibody
This patient has Wegener’s granulomatosis, a systemic vasculitis affecting small and medium sized vessels. The classic triad includes upper and lower respiratory tract involvement and GN. Musculoskeletal manifestations such as arthralgia and signs of thromboembolism are commonly seen. A positive cANCA (antigen being proteinase 3) in the setting of the classic triad is sufficient to diagnose Wegener’s. Urinalysis and microscopy is also indicated to reveal renal involvement and a CT chest may reveal lung involvement, particularly in those who are asymptomatic for pulmonary involvement. This may show nodules or infiltrates.
An 80-year-old man with diabetes presents with black right great and second toes. He also has an ulcer on the ball of the foot. Most appropriate investigation? A. Blood sugar B. Arteriogram C. Cold provocation test D. Full blood count E. CT scan F. Venous duplex scan G. Blood cultures H. Lumbar puncture I. Anti-neutrophil cytoplasmic antibody
Arteriogram
Diabetic neuropathy has lead to the painless ulcer developing over pressure points in the foot such as on the ball of this man’s foot. This may have resulted from an object becoming lodged in the shoe and eroding through the skin with walking. This is why it is important for diabetics to check their feet regularly and to wear specialised footwear. The black toes on his right foot are likely due to peripheral vascular disease. It is worth noting that peripheral vascular disease refers specifically to peripheral arterial disease. The first line study is an ABPI although an arteriogram can be done to identify areas of stenoses which can be treated surgically. The black mummified toes may have to be amputated.
A 25-year-old Sikh presents 3 months after arrival in the UK with anaemia and an enlarged spleen. He gives history of intermittent febrile episodes. Most appropriate investigation? •Thick blood film •Haemoglobin electrophoresis •Upper GI endoscopy •Colonoscopy •Anti-gliadin antibodies •Thin blood film •Serum ferritin •Urea and electrolytes •Faecal occult blood •Faecal fats •Bone marrow biopsy •Barium meal and follow through
Thick blood film
In the Western world, almost all cases of malaria occurs in travellers so an adequate travel history is crucial or the diagnosis may be missed. Patients typically present with non-specific symptoms such as a fever, sweats, chills and myalgia. This Sikh may have just arrived from an endemic area. Sometimes EMQs will describe patterns of fevers occuring at regular intervals of 48-72 hours associated with P. vivax, P. ovale and P. malariae infections but in most patients there is no specific pattern. Hepatosplenomegaly is a common presenting sign, although in the Western world, it is not common on initial presentation.
The test of choice is Giesma-stained thick and thin blood smears. Thick films sensitively detect parasites whereas thin films allow species identification and calculation of parasitaemia to guide treatment. In this case, if you had to pick one, then the thick film would be more useful in establishing the diagnosis. Studies have shown that for P falciparum, the most effective treatment is artesunate which is more effective than quinine without the risk of cinchonism. However, not all hospitals are currently licensed to use it in the UK (in London, only the Hospital for Tropical Diseases and Northwick Park). Artesunate is manufactured by a pharmaceutical company in China and there are doubts over the quality of the product. However, there have now been numerous studies such as the AQUAMAT study in The Lancet showing that quinine should no longer be the established treatment of choice.
A 62-year-old man with chronic mechanical low back pain which has been treated with ibuprofen. He presents with bilateral ankle oedema and dyspnoea. He is found to have a haemoglobin of 7.2g/dL and has epigastric tenderness. Most appropriate investigation? •Thick blood film •Haemoglobin electrophoresis •Upper GI endoscopy •Colonoscopy •Anti-gliadin antibodies •Thin blood film •Serum ferritin •Urea and electrolytes •Faecal occult blood •Faecal fats •Bone marrow biopsy •Barium meal and follow through
Upper GI endoscopy
This patient is anaemic due to a bleeding peptic ulcer which has resulted from prolonged NSAID use. Dyspnoea is a symptom here and the ankle oedema could be due to high output heart failure. The most specific and sensitive test is an upper GI endoscopy. Duodenal ulcers rarely undergo malignant transformation so do not require a compulsory biopsy but gastric ulcers require biopsies to rule this out. Management is aimed at correcting the underlying cause such as discontinuing NSAIDs in this case. H. pylori eradication should be started if the organism is present with triple therapy. Otherwise, a PPI is indicated.
A 71-year-old woman presents with early morning diarrhoea of 3 months duration and is found to be anaemic. There is no obstruction on digital rectal examination, but blood is noticed on the finger stall. Most appropriate investigation? •Thick blood film •Haemoglobin electrophoresis •Upper GI endoscopy •Colonoscopy •Anti-gliadin antibodies •Thin blood film •Serum ferritin •Urea and electrolytes •Faecal occult blood •Faecal fats •Bone marrow biopsy •Barium meal and follow through
Colonoscopy
Anaemia in this case is a sinister sign which could point to possible malignancy, particularly given the patient’s advanced age. There is GI bleeding here, presumed to be lower GI, which needs to be investigated with a colonoscopy.
A 40-year-old man who has been investigated for iron deficiency anaemia has a normal upper GI endoscopy and colonoscopy. A barium meal and follow through was also unhelpful. Most appropriate investigation? •Thick blood film •Haemoglobin electrophoresis •Upper GI endoscopy •Colonoscopy •Anti-gliadin antibodies •Thin blood film •Serum ferritin •Urea and electrolytes •Faecal occult blood •Faecal fats •Bone marrow biopsy •Barium meal and follow through
Anti-gliadin antibodies
This man is being investigated for a microcytic IDA here. The cause is not dietary iron intake given the history. So this could still be due to inadequate absorption such as coeliac disease or loss from GI bleeding. The unremarkable endoscopy results and barium studies indicate the absence of GI bleeding. This leaves coeliac disease, or potentially idiopathic, but the next thing to do here is to investigate the possibility of coeliac disease. Coeliac most common presents with IDA, although it can also lead to a macrocytic anaemia with mainly folate deficiency (though B12 is also affected but hepatic stores last several years). It is an autoimmune condition triggered by gluten peptides found in wheat, rye and barley. The ultimate best test is duodenal biopsy and histology to show intra-epithelial lymphocytes, villous atrophy and crypt hyperplasia. Macroscopic changes may be present but endoscopy is generally unhelpful, as in this case. The test of choice before performing such an invasive confirmatory test is to look for elevated anti-gliadin antibodies. Anti-tissue transglutaminase is less accurate and endomysial antibody is more expensive and has lower sensitivity.
A 45-year-old man with a long history of excess alcohol consumption presents with haematemesis. On examination he is clubbed and has spider naevi.
Most appropriate investigation?
A. Bronchoscopy B. Chest x-ray C. Stool culture D. Lung function tests E. Abdominal ultrasound scan F. Colonoscopy G. Echocardiogram H. Sputum culture
Abdominal ultrasound scan
This is clubbing due to cirrhosis as a result of chronic alcohol excess. Ultrasound here is the only feasible option on the list and can detect advanced cirrhosis and possible signs of portal hypertension, such as ascites, splenomegaly and increased portal vein diameter. The ultrasound may show a nodular liver surface, the liver may itself be shrunk due to cirrhosis and the left hand side of the liver may be hypertrophied. USS findings with a good clinical suspicion is enough for diagnosis.
A 19-year-old woman with a past history of cardiac surgery in infancy presents with symptoms of decreasing exercise tolerance. On examination there is cyanosis and clubbing
Most appropriate investigation?
A. Bronchoscopy B. Chest x-ray C. Stool culture D. Lung function tests E. Abdominal ultrasound scan F. Colonoscopy G. Echocardiogram H. Sputum culture
Echocardiogram
The only cardiac investigation here is an echocardiogram. Cardiovascular causes of clubbing include cyanotic congenital heart disease, infective endocarditis and atrial myxoma. This could well be Eisenmenger’s syndrome caused by shunt reversal.
A 50-year-old woman, who gave up smoking 5 years ago, presents with SOB and weight loss. On examination she is clubbed. The CXR shows a perihilar shadow.
Most appropriate investigation?
A. Bronchoscopy B. Chest x-ray C. Stool culture D. Lung function tests E. Abdominal ultrasound scan F. Colonoscopy G. Echocardiogram H. Sputum culture
Bronchoscopy
The history of smoking and weight loss point to a bronchial carcinoma. Whilst the initial investigation is with a CXR, diagnosis relies on pathological confirmation from a tissue sample, often obtained from bronchoscopy. Non-small cell lung cancer is more often associated with clubbing.
A 30-year-old man presents with an intermittent swelling in the right scrotum. Examination demonstrates a soft, compressible lump in the scrotum, the upper limit of which cannot be palpated.
Hernia - on examination, a direct hernia cannot be controlled by pressure at the midpoint of the inguinal ligament whereas an indirect hernia can be controlled by occlusive pressure.
A 22-year-old medical student has several episodes of vomiting blood after a period of forceful retching. He had been binge drinking for the last 3 days after failing his OSCE.
Choose the SINGLE most appropriate diagnostic investigation from the list: -
A. H.pylori breath test B. Colonoscopy C. Chest x-ray D. Liver biopsy E. Full blood count F. CT scan abdomen G. Upper GI endoscopy H. Liver function test I. Barium swallow J. Upper GI endoscopy K. Clotting profile
Upper GI endoscopy
The definitive diagnosis for a Mallory-Weiss tear is made by OGD. This tear in the oesophageal mucosa occurs after a rise in abdominal pressure, causing subsequent GI bleeding. It commonly presents with haematemesis after an episode of retching/vomiting/coughing/straining. Hence, risk factors include anything which can cause vomiting like heavy alcohol use, which is commonly the case in EMQs. Also, other conditions would include food poisoning, bowel obstruction, hyperemesis gravidarum, bulimia, the chronic cough of COPD, meningitis etc… you name it really. Classically, MWT presents with a small self limiting episode of haematemesis. Treatment is supportive because most cases are self limiting and emergency treatment is not offered unless the patient is showing signs of clinical instability. If the patient is actively bleeding, treatment will be with therapeutic endoscopy in most cases, and very very few cases will require more intervention such as angiography with embolisation.
A 60-year-old woman presents with a poor appetite, weight loss, tiredness and intermittent right iliac fossa discomfort for the last six weeks.
Choose the SINGLE most likely diagnosis:-
A. Caecal carcinoma B. Meckel's diverticulum C. Anal fissure D. Duodenal ulcer E. Diverticular disease F. Haemorrhoids G. Rectal carcinoma H. Acute ischaemic bowel I. Crohn's disease J. Infective diarrhoea K. Ulcerative colitis
Caecal carcinoma
The weight loss, fatigue and RIF discomfort point to caecal carcinoma. Right sided colorectal cancer tends to present with anaemic symptoms. Almost 90% are anaemic at diagnosis.
A 30-year-old man presents with painless fresh rectal bleeding which appears on the stool, on the paper and in the toilet bowel.
Choose the SINGLE most likely diagnosis:-
A. Caecal carcinoma B. Meckel's diverticulum C. Anal fissure D. Duodenal ulcer E. Diverticular disease F. Haemorrhoids G. Rectal carcinoma H. Acute ischaemic bowel I. Crohn's disease J. Infective diarrhoea K. Ulcerative colitis
Haemorrhoids
Haemorrhoids are vascular rich cushions in the anal canal and presents, typically, as painless bright PR bleeding or with sudden onset pain in the area associated with a palpable mass. Pruritus ani is common and there is often perianal pain or discomfort. Diagnosis is made visually. Grade 1 is limited to within the anal canal. Grade 2 protrudes but spontaneously reduces when the patient stops straining. Grade 3 protrudes and reduces fully on manual pressure. Grade 4 is irreducible. Treatment includes fibre, ligation, photocoagulation, sclerotherapy or surgical haemorrhoidectomy. Haemorrhoidectomy is the treatment of choice of choice for patients with grade 4 haemorrhoids or for any patient who has failed with more conservative treatment such as sclerotherapy.
A 70-year-old man with atrial fibrillation presents with a two hour history of general abdominal discomfort and is shocked. He has passed bloody diarrhoea.
Choose the SINGLE most likely diagnosis:-
A. Caecal carcinoma B. Meckel's diverticulum C. Anal fissure D. Duodenal ulcer E. Diverticular disease F. Haemorrhoids G. Rectal carcinoma H. Acute ischaemic bowel I. Crohn's disease J. Infective diarrhoea K. Ulcerative colitis
Acute ischaemic bowel
Untreated AF can lead to a thrombus forming inside the heart which can then embolise like this case to the mesenteric vasculature. This person is also old, which is an additional risk due to comorbidities like atherosclerosis. This patient has the symptoms and signs of ischaemic bowel disease (which encompasses acute mesenteric ischaemia, chronic mesenteric ischaemia and colonic ischaemia). This is likely acute mesenteric ischaemia – something that in a person who presents like this, you should maintain a high index of suspicion for as the presentation can be quite non-specific but the condition can be deadly. You would likely in this case opt for surgical intervention without delay although you can consider some form of imaging.
What is the most appropriate monitoring investigation for Warfarin?
INR
A 60-year-old man with diabetes is transferred from another hospital for urgernt femoral-distal bypass surgery and arrives with a heparin infusion in situ. His APTT is 2.4 Which analgesia is contraindicated?
A. Diclofenac B. Epidural bupivacaine C. Codydamol D. Paracetamol E. Morphine
Epidural - contraindicated in anticoagulated patients
A 62-year-old man who requires a knee replacement gives a history of allergy to dihydrocodeine. Which analgesia is contraindicated? A. Diclofenac B. Epidural bupivacaine C. Codydamol D. Paracetamol E. Morphine
Codydramol - combination of dihyrocodeine and paracetamol
A 59-year-old man presents with a one month history of constipation, tenesmus and fresh rectal bleeding. He also notes some weight loss recently.
Choose the SINGLE most likely diagnosis:-
A. Caecal carcinoma B. Meckel's diverticulum C. Anal fissure D. Duodenal ulcer E. Diverticular disease F. Haemorrhoids G. Rectal carcinoma H. Acute ischaemic bowel I. Crohn's disease J. Infective diarrhoea K. Ulcerative colitis
Rectal carcinoma
This a rectal carcinoma. Tenesmus, blood PR alongside weight loss are all highly suggestive. Treatment of rectal carcinoma involves surgical excision where possible. This can either be an anterior resection (tumours in the upper 1/3 of the rectum) or an abdominoperineal resection (if the tumour lies lower down). APER involves the formation of a permanent colostomy and has a high incidence of sexual and urinary dysfunction. Anterior resection involves a colo-anal anastamosis.
A 30 year old male alcoholic presents nausea and pain in the lower chest in a band radiating around to the back. The pain makes the patient curl up in a ball and movement worsens it. On examination there is decreased breath sounds on the left side which is stony dull to percussion at the base. Most useful investigation?
CT scan abdomen, serum amylase or lipase are also key to diagnosis - patient has acute pancreatitis
A 55-year-old motor dealer’s wife has threatened to leave him unless he stops drinking. He presents with a short history of acute anxiety and visual hallucinations.
Delirium tremens from alcohol withdrawal. Alcohol excess can also cause delirium secondary to alcoholic ketoacidosis and can also be seen in Wernicke’s or Korsakoff’s.
A 45-year-old woman complains of abdominal pain for several months. On examination she is jaundiced with a distended abdomen and skin telangiectasia. Complication of alcohol abuse?
Cirrhosis - the end stage of chronic liver disease, results in hepatic insufficiency and portal hypertension, causing jaundice.
A middle-aged tramp presents in A&E intoxicated and confused. He has a half-finished bottle of vodka in his pocket. Additionally there is horizontal gaze palsy and severe ataxia with vertigo and headache
Wernicke’s encephalopathy - due to acute thiamine deficiency. Triad = mental change, opthalmoplegia, gait dysfunction.
50 year old man took OD of antidepressants an hour ago. has dry mouth, dilated pupils but not drowsy. best treatment?
Oral methionine? Activated Charcoal? Gastric lavage? Forced emesis? Physostigmine?
Activated Charcoal overdose of tricyclic antidepressants which are a class of drugs with a narrow therapeutic index and become potent toxins in moderate doses in CNS and CVS. main aim of treatment is to provide reap and CVS support until medicine has been fully metabolised and eliminated. GI decontamination should be considered in those presenting with early OD (under 2 hours) warm dry skin part of anticholinergic effect (don't reverse with Physostigmine as can cause systole)
A 55-year-old woman has been drinking heavily for 3 months since her husband left her. Her son is concerned that she rarely goes out and often does not get dressed.
Depression
30 year old woman with toothache has taken 50 paracetamol 500mg tablets in the last 24 hours. she feels nauseated and still has toothache but is otherwise well. best treatment?
Activated Charcole? Forced emesis? Gastric lavage? N-acetylcysteine? Hyperbaric O2?
N-acetylcysteine
serum paracetamol level is important to order as early as possible but at the earliest 4 hours post-ingestion. Treatment if indicated is with N-acetylcysteine with the level based on paracetamol treatment graph.
20 year old heroin addict arrives in casualty, unconscious and cyanosed. His reap rate is 6/min and he has pin-point pupils. best treatment?
IV-glucagon? Haemodialysis? IV-naloxone? Forced alkaline diuresis?
IV-naloxone
Signs of opiate OD include CNS depression, mitosis and apnoea. Naloxone is indicated both therapeutically and diagnostically. if response then its diagnostic. Another diagnosis should be sought if unresponsive. IV is preferred route although naloxone can be given IM of IC. Ventilatory support is key with 100% O2
A 25-year-old man presents with a 6 month history of painless enlargement of the left hemiscrotum. The swelling is fluctuant, translucent, confined to the scrotum, and the testis cannot be felt separately.
Hydrocoele - a collection of serous fluid between the layers of the tunica vaginalis. Mainly presents with a painless swollen scrotum, feels like a water-filled balloon.
A 23 year old man has a dull ache in the left scrotum. He has noticed a firm, 2cm, non-tender lump at the front of the testicle. He has palpable supraclavicular lymph nodes.
Testicular malignancy - most commonly presents as a hard, painless lump on one testis - 10% present with acute pain associated with haemorrhage or infection.
A 70-year-old man present with mild dysuria, urinary hesitancy and terminal dribbling. He also has bilateral testicular pain, swelling and tenderness of both testes and epididymis. His temperature is 37.50ºC
Epididymo-orchitis - younger men are more likely to have an STI whereas older men are more likely to have an infection with enteric organisms such as ESBL. A urethral swab should be sent for Gram stain and culture of secretions. A urin dipstick is also necessary comined with urine MC&S. Treatment: bed rest, scrotal elevation, analgesia and antibiotics.
A 64-year-old, previously obese woman complains of weight loss, despite increased appetite and says she has been treating herself for ‘repeated urine infections’. She also says that over the last few months she has been getting pins and needles in her legs. Most apt initial investigation?
Fasting blood glucose
A 35-year-old woman has noticed some changes in her right breast that are worse before her periods. You find a tender, diffuse, lumpy area in the upper outer quadrant about 10cms by 5cms with no lymphadenopathy.
Fibroadnosis - associated with pain which fluctuates with the menstrual cycle (it is worse during the luteal phase of menses).
A 17-year-old man presents with a 6 hour history of sudden onset of severe left scrotal pains. The scrotum is red and swollen, the testis and epididymis are very tender.
Testicular torsion - urological emergency caused by twisting of the testicle on the spermatic cord. If not fixed will lead to ischaemia and necrosis of the tissue. Boys aged 12-18 are at greater risk.
A 55-year-old woman with a 6-week history of intermittent angina is found to have a serum cholesterol of 7.9 mmol/l. Next stage in management?
Perform exercise ECG - stable angina will show ST segment depression during exercise indicative of ischaemia.
A 41-year-old woman of Mediterranean descent is found to be anaemic. She has hepatosplenomegaly and normal haematinics. Most appropriate investigation? •Thick blood film •Haemoglobin electrophoresis •Upper GI endoscopy •Colonoscopy •Anti-gliadin antibodies •Thin blood film •Serum ferritin •Urea and electrolytes •Faecal occult blood •Faecal fats •Bone marrow biopsy •Barium meal and follow through
Haemoglobin electrophoresis
This is beta-thalassaemia, either major or intermedia due to the findings of abdominal distension, skeletal changes and hepatosplenomegaly which is not seen in heterozygoud beta-thalassaemia trait. The pallor is highly suggestive of moderate to severe anaemia, confirmed by the test results. Beta-thalassaemia major (or Cooley anaemia) is due to a complete abscence of HbA and often presents at a few months of age with pallor and abdominal distension, both described by parents as being progressive in nature. HSM and bony abnormalities (most often the frontal and parietal bossing mentioned, as well as ‘chipmunk facies’) are often present at presentation. Intermedia has a similar presentation but in a toddler or older child, with less pronounced symptoms and a more insidious course. Blood transfusions are required though stem cell transplant offers a hope of a cure. Hb electrophoresis will reveal minimal or no HbA and elevated HbF and HbA2.
A 36-year-old woman complains of right loin pain and gross haematuria. She is discovered to be hypertensive. Abdominal examination reveals a palpable renal mass. There is FH of kidney failure and SAH. Plasma creatinine is normal.
Autosomal dominant Polycystic kidney disease - patient might have a FH, PKD or ESRF or cerebrovascular events (intracranial berry aneurysms in the circle of Willis and subsequent SAH)
An 80-year-old man with a history of ischaemic heart disease trips over a paving stone and fractures his hip. An ambulance takes him to A&E. 1 hour after arrival, he develops crushing central chest pain. Most useful investigation?
ECG - presenting with an MI
A 19 year old male medical student develops acute chest pain during a game of squash. On examination he is distressed there but examination is otherwise unremarkable. There is a family history of sudden death. Most useful investigation?
Transthoracic echo - patient likely has HOCM. Patient’s young age makes it unlikely to be atherosclerotic coronary artery disease (unstable angina).
A 56 year old man on NSAIDs and amoxicillin for bronchitis develops a rash. He is mildy febrile despite the resolution of his bronchitis. The patient is confirmed to be in acute renal failure with elevated urea and creatinine and there is also pedal oedema. He is not oliguric. FBC shows eosinophilia.
Acute interstitial nephritis - classically presents with acute renal failure associated with oligouria and the ‘hypersensitivity triad’ of rash, fever, and eosinophilia triggered by a drug e.g antibiotics, and NSAIDs.
A 55 year old obese female complains of a 6 month history of chest pain which radiated to the jaw and both shoulders. The pain is reported to be more severe at night. ECG and chest x-rays are normal. Most useful next investigation?
Upper GI endoscopy - patient has GORD characterised by heartburn and acid regurgitation.
A 28 year old man presents with haematemesis and a 3 month history of abdominal pain. His BP is 82/41, HR 119 and afebrile. His peripheries feel cool to touch. He is catheterised and you note decreased urine output. Urine and creatinine is elevated and the consultant asks you why his kidneys are compromised.
Shock - there is inadequate organ perfusion and when this includes the kidneys you get renal hypoperfusion which can progress to acute renal failure.
28yo woman, has carcinoma of the cervix, presents to A&E with an inability to urinate for 8 hours. Severe lower abdo pain, distension (dull to percuss), weak stream and nocturia. Plasma creat = 250, BP = 130/80. Urinalysis is -ve.
Obstructive uropathy - caused by a block in urinary flow by the cervical carcinoma affecting the urinary tract.
An 80 year old woman on corticosteroids develops acute chest pain while standing up. It is posteriorly sited, radiating anteriorly under the breast. The pain is worse on movement and there is tenderness on the back of the chest. Cardiovascular and respiratory examination are normal. Most useful investigation?
Thoracic spine x-ray - patient likely has osteoporotic vertebral collapse/fracture which is compressing the intercostal nerve and causing her sudden pain in the back of her chest. History of Corticosteroid use is also associated with osteoporosis.
83-year-old man with longstanding heart failure for which he takes Digoxin and diuretics. For the last 24 hours he has been vomiting and has passed very little urine. On examination he is pale and mildly dehydrated; examination of the abdomen is normal.
Uraemia - patient has developed acute renal failure, probably associated with longstanding CCF. Advance HF will lead to depressed renal perfusion and ARF.
A 26-year-old, anxious teacher with diffuse headaches, SOB and tingling in the hands. Blood gas measurement shows low PCO2, but high normal PO2. pH is 7.49. Management?
Re-breathing
An 18-year-old develops fever, photophobia and neck stiffness. There is also confusion and vomiting as well as a petechial rash. A CT scan is needed but someone is already in the CT scanner. Management?
IV antibiotics
A 32-year-old man presents 24 hours after the sudden onset of the worst headache of his life. He has no history of headaches, is afebrile but has neck stiffness and is drowsy. CT scan is normal. next test?
Lumbar puncture
A 53-year-old smoker presents with a seizure, unilateral headaches for 3 months and 10kg of weight loss. Management?
CT head
A 17-year-old woman with a FH of headaches has now herself developed headaches which are throbbing in character and preceded by flashing lights. She wonders what her GP can do for her. Management?
Aspirin
What is the most appropriate monitoring investigation for ACEi?
Renal function tests
What is the most appropriate monitoring investigation for Pravastatin?
Liver function test
What is the most appropriate monitoring investigation for Phenytoin?
Serum drug level
A 23 year old man has a dull ache in the left scrotum. He has noticed a firm, 2cm, non-tender lump at the front of the testicle. He has palpable supraclavicular lymph nodes.
Testicular malignancy
A 59-year-old man presents with a one month history of constipation, tenesmus and fresh rectal bleeding. He also notes some weight loss recently.
Choose the SINGLE most likely diagnosis:-
A. Caecal carcinoma B. Meckel's diverticulum C. Anal fissure D. Duodenal ulcer E. Diverticular disease F. Haemorrhoids G. Rectal carcinoma H. Acute ischaemic bowel I. Crohn's disease J. Infective diarrhoea K. Ulcerative colitis
Rectal carcinoma
This a rectal carcinoma. Tenesmus, blood PR alongside weight loss are all highly suggestive. Treatment of rectal carcinoma involves surgical excision where possible. This can either be an anterior resection (tumours in the upper 1/3 of the rectum) or an abdominoperineal resection (if the tumour lies lower down). APER involves the formation of a permanent colostomy and has a high incidence of sexual and urinary dysfunction. Anterior resection involves a colo-anal anastamosis.
What is the most appropriate monitoring investigation for Phenytoin?
Serum drug level
A 50-year-old man presents with acute ST elevation MI to London’s best hospital. He has already been given aspirin, oxygen, morphine and GTN and is haemodynamically stable. 20 minutes have passed since symptom onset. Next step in management?
Perform coronary angioplasty
A 65-year-old woman presents with acute DVT. There is a low risk for bleeding. This step is added along with warfarin therapy. Next step in management?
Add low molecular weight heparin, could also be a factor Xa inhibitor (e.g. Fondaparinux) or normal Heparin
A 45-year-old man with a long history of excess alcohol consumption presents with haematemesis. On examination he is clubbed and has spider naevi.
Most appropriate investigation?
A. Bronchoscopy B. Chest x-ray C. Stool culture D. Lung function tests E. Abdominal ultrasound scan F. Colonoscopy G. Echocardiogram H. Sputum culture
Abdominal ultrasound scan
A 57-year-old Asian male smoker was treated successfully for pulmonary TB last year. He has had nausea for a month and over the last week has vomited after every solid meal. He has lost 5 kg in weight in that period and has some abdominal discomfort. He feels food getting stuck behind the bottom of his sternum. Examination is unremarkable. Most appropriate initial investigation?
Gastroscopy
A 73-year-old ex-smoking male consults you because he is polysymptomatic, including 3 kg weight loss, memory loss and sleep disturbance. His family are worried because he lives on his own, following the death of his wife last year. He has given up his gardening and says he doesn’t want to meet his friends any more. Most apt initial investigation?
History only
An 83-year-old lady complains of feeling tired and breathless on exertion since a brief episode six weeks ago which another doctor diagnosed as gastroenteritis. However, the diarrhoea has not improved. A blood test you did last week shows a microcytic anaemia. Most apt initial investigation?
Colonoscopy
A 32-year-old male nurse from Zimbabwe came into the UK as part of an NHS recruitment campaign. He presents with SOB, weight loss, general debility, cervical lymphadenopathy and purple tender lesions on his shin of 6 weeks duration. Most apt initial investigation?
Chest x-ray
A 36-year-old woman complains of right loin pain and gross haematuria. She is discovered to be hypertensive. Abdominal examination reveals a palpable renal mass. There is FH of kidney failure and SAH. Plasma creatinine is normal.
Polycystic kidney disease
A 70-year-old retired pigeon-fancier becomes cyanosed on exercise. He has a persistent cough and progressive shortness of breath. There are fine crackles at both lung bases on auscultation
Extrinsic allergic alveolitis - variety of syndromes it could be: pidgeon breeder’s lung, bird fancier’s lung, budgerigar fancier’s disease.
An 82-year-old woman woke up at night acutely short of breath, with a frothy cough and wheeze. She had a myocardial infarction 6 months previously.
Acute left ventricular failure - causes congestion in the pulmonary circulation so the symptoms are respiratory.
A 77 year old man presents with a 3 day history of constant left iliac fossa pain. She has a temp of 38 degrees and O/E is tender with guarding in the left iliac fossa. CT scan demonstrates an inflamed sigmoid colon with numerous diverticulae. next step?
CXR? PR? Endoscopy?CT? Laparotomy? Oral antibiotics? AXR? USS?
Oral antibiotics
patient has diverticulitis and doesn’t need further investigations. Symptomatic diverticulitis presents with fever, high WCC and LLQ pain. risk factors include low dietary fibre and advanced age. oral antibiotics and analgesia is indicated
A 68-year-old ex-smoker on inhalers and long-term oxygen therapy is found to have bilateral peripheral oedema.
COPD - second pulmonary hypertension as a result of the advanced COPD or cor-pulmonale has caused peripheral oedema.
A 22-year-old man is found with CNS and respiratory depression at his bedsit. He has track marks on both upper arms and you see a syringe on the carpet. You notice his pupils are constricted.
Opiate intoxication - signs include CNS depression, miosis, and apnoea. with cocaine you would have dilated pupils. Naloxone is indicated both therapeutically and diagnostically.
An 80-year-old man with a history of ischaemic heart disease trips over a paving stone and fractures his hip. An ambulance takes him to A&E. 1 hour after arrival, he develops crushing central chest pain. \Most useful investigation?
ECG
80yo woman present with recent onset effort related chest pain. There is a loud ejection systolic murmur and a low pulse pressure with a slow rising pulse.
Aortic stenosis
A 60-year-old woman presents with a poor appetite, weight loss, tiredness and intermittent right iliac fossa discomfort for the last six weeks.
Choose the SINGLE most likely diagnosis:-
A. Caecal carcinoma B. Meckel's diverticulum C. Anal fissure D. Duodenal ulcer E. Diverticular disease F. Haemorrhoids G. Rectal carcinoma H. Acute ischaemic bowel I. Crohn's disease J. Infective diarrhoea K. Ulcerative colitis
Caecal carcinoma
The weight loss, fatigue and RIF discomfort point to caecal carcinoma. Right sided colorectal cancer tends to present with anaemic symptoms. Almost 90% are anaemic at diagnosis.
A 30 year old male alcoholic presents nausea and pain in the lower chest in a band radiating around to the back. The pain makes the patient curl up in a ball and movement worsens it. On examination there is decreased breath sounds on the left side which is stony dull to percussion at the base. Most useful investigation?
CT scan abdomen - patient has acute pancreatitis
A 24-year-old man is found in the toilet of his girlfriend’s flat slumped on the floor the morning after his stag night. He is taken to A&E where he is found to have a serum creatinine level of 350 μmol/l.
Rhabdomyolysis - myocyte lysis. Alcohol is directly toxic to myocyte membranes, inhibiting calcium uptake and disrupting the sodium-potassium pump.
A 30-year-old man presents with painless fresh rectal bleeding which appears on the stool, on the paper and in the toilet bowel.
Choose the SINGLE most likely diagnosis:-
A. Caecal carcinoma B. Meckel's diverticulum C. Anal fissure D. Duodenal ulcer E. Diverticular disease F. Haemorrhoids G. Rectal carcinoma H. Acute ischaemic bowel I. Crohn's disease J. Infective diarrhoea K. Ulcerative colitis
Haemorrhoids
Haemorrhoids are vascular rich cushions in the anal canal and presents, typically, as painless bright PR bleeding or with sudden onset pain in the area associated with a palpable mass. Pruritus ani is common and there is often perianal pain or discomfort. Diagnosis is made visually. Grade 1 is limited to within the anal canal. Grade 2 protrudes but spontaneously reduces when the patient stops straining. Grade 3 protrudes and reduces fully on manual pressure. Grade 4 is irreducible. Treatment includes fibre, ligation, photocoagulation, sclerotherapy or surgical haemorrhoidectomy. Haemorrhoidectomy is the treatment of choice of choice for patients with grade 4 haemorrhoids or for any patient who has failed with more conservative treatment such as sclerotherapy.
A 30-year-old stockbroker with a chronic band-like headache for 2 years. The headache is related to stressful work. Management?
Paracetamol
A 26-year-old, anxious teacher with diffuse headaches, SOB and tingling in the hands. Blood gas measurement shows low PCO2, but high normal PO2. pH is 7.49.
Re-breathing
An 18-year-old develops fever, photophobia and neck stiffness. There is also confusion and vomiting as well as a petechial rash. A CT scan is needed but someone is already in the CT scanner.
IV antibiotics
A 53-year-old smoker presents with a seizure, unilateral headaches for 3 months and 10kg of weight loss.
CT head
A 17-year-old woman with a FH of headaches has now herself developed headaches which are throbbing in character and preceded by flashing lights. She wonders what her GP can do for her.
Aspirin
A 49-year-old man with a five year history of dyspepsia collapses in the pub. He has noticed that his stools have become black over the last few days.
Choose the SINGLE most likely diagnosis:-
A. Caecal carcinoma B. Meckel's diverticulum C. Anal fissure D. Duodenal ulcer E. Diverticular disease F. Haemorrhoids G. Rectal carcinoma H. Acute ischaemic bowel I. Crohn's disease J. Infective diarrhoea K. Ulcerative colitis
Duodenal ulcer
There is no reason why this cannot be a gastric ulcer but it is not an option on the list. The history of dyspepsia and black tarry stools over the past few days suggests a bleeding peptic ulcer. The dyspepsia is often centred in the upper abdomen and is related to eating. Contrary to popular lay health beliefs there is no good evidence of alcohol as an important risk factor. Key risk factors are NSAID use, H. pylori, smoking and FH of PUD. The most specific and sensitive test is an upper GI endoscopy which will also allow intervention to stop the bleeding ulcer from bleeding. Duodenal ulcers rarely undergo malignant transformation so do not require a compulsory biopsy but gastric ulcers require biopsies to rule this out. Management is aimed at correcting the underlying cause such as discontinuing NSAIDs. H. pylori eradication should be started if the organism is present with triple therapy. Otherwise, a PPI is indicated.
Match the cause of hypotension to the following case history:
33-year-old woman complains of giddiness on standing and can no longer cross a road on her own as she is worried that she may pass out. She developed diabetes when aged 12 and had laser treatment to her eyes 2 years ago
Autonomic neuropathy
Autonomic neuropathy is a complication of diabetic neuropathy. Symptoms of autonomic neuropathy include… resting tachycardia (late findings due to vagal impairment), impaired HR variation, erectile dysfunction (affects many diabetic men though is not solely due to autonomic neuropathy), decreased libido and dyspareunia, orthostatic hypotension (measure BP supine and then standing after 1, 2, 3 and sometimes 5 minutes – an abnormal drop when standing is indicative) and urinary symptoms of frequency, urgency, incontinence, nocturia, weak stream and retention. Other symptoms include constipation, faecal incontinence and sweating dysfunction. Fludrocortisone may be helpful in this woman.
A 68-year-old woman presents with a two day history of passing copious quantities of blood per rectum and a fever. She has also had left iliac fossa pain during this period.
Choose the SINGLE most likely diagnosis:-
A. Caecal carcinoma B. Meckel's diverticulum C. Anal fissure D. Duodenal ulcer E. Diverticular disease F. Haemorrhoids G. Rectal carcinoma H. Acute ischaemic bowel I. Crohn's disease J. Infective diarrhoea K. Ulcerative colitis
Diverticular disease
Symptomatic diverticulitis presents with fever, high WCC and LLQ pain. There may uncommonly be rectal bleeding which is usually painless, profuse and arterial in nature. Risk factors for diverticular disease include low dietary fibre and advanced age. Oral antibiotic therapy and analgesia is indicated. If there is no improvement in 72 hours after oral antibiotics then IV antibiotics are indicated. Make sure you understand the differences in the terms: diverticulosis, diverticulitis and diverticular disease.
What is the most appropriate monitoring investigation for ACEi?
Renal function tests
What is the most appropriate monitoring investigation for Pravastatin?
Liver function test
What is the most appropriate monitoring investigation for Cyclophosphamide?
WCC
A 50-year-old man presents with acute ST elevation MI to London’s best hospital. He has already been given aspirin, oxygen, morphine and GTN and is haemodynamically stable. 20 minutes have passed since symptom onset. Next step in management?
Perform coronary angioplasty
A 65-year-old woman presents with acute DVT. There is a low risk for bleeding. This step is added along with warfarin therapy. Next step in management?
Add low molecular weight heparin
A 55-year-old woman with history of recurrent falls and collapse, presented with intermittent angina-like chest pains. On examination, she has a low pulse volume and an ejection systolic murmur in the aortic region. Next stage in management?
Perform echocardiography - Doppler exho is best diagnosis and evaluation of aortic stenosis and is highly sensitive and specific. It will show an elevated aortic pressure gradient and also allow you to quantify LV ejection function and measure the are of the valve.
A 55-year-old woman with a 6-week history of intermittent angina is found to have a serum cholesterol of 7.9 mmol/l. Next stage in management?
Perform exercise ECG - stable angina will show ST segment depression during exercise indicative of ischaemia.
A 57-year-old Asian male smoker was treated successfully for pulmonary TB last year. He has had nausea for a month and over the last week has vomited after every solid meal. He has lost 5 kg in weight in that period and has some abdominal discomfort. He feels food getting stuck behind the bottom of his sternum. Examination is unremarkable. Most appropriate initial investigation?
Gastroscopy
A 73-year-old ex-smoking male consults you because he is polysymptomatic, including 3 kg weight loss, memory loss and sleep disturbance. His family are worried because he lives on his own, following the death of his wife last year. He has given up his gardening and says he doesn’t want to meet his friends any more. Most apt initial investigation?
History only
What is the most appropriate monitoring investigation for Warfarin?
INR
A 64-year-old, previously obese woman complains of weight loss, despite increased appetite and says she has been treating herself for ‘repeated urine infections’. She also says that over the last few months she has been getting pins and needles in her legs. Most apt initial investigation?
Fasting blood glucose
An 83-year-old lady complains of feeling tired and breathless on exertion since a brief episode six weeks ago which another doctor diagnosed as gastroenteritis. However, the diarrhoea has not improved. A blood test you did last week shows a microcytic anaemia. Most apt initial investigation?
Colonoscopy
A 32-year-old male nurse from Zimbabwe came into the UK as part of an NHS recruitment campaign. He presents with SOB, weight loss, general debility, cervical lymphadenopathy and purple tender lesions on his shin of 6 weeks duration. Most apt initial investigation?
Chest x-ray
A 78-year-old man presents with low back pain that doesn’t improve with rest. He has non-specific intermittent abdominal pain and night sweats. Investigations reveal a haemoglobin of 9.6 g/dL, a corrected calcium of 2.97 mmol/L, and an ESR > 100 mm/hr. Most apt initial investigation?
Bone marrow aspirate
A 70-year-old retired pigeon-fancier becomes cyanosed on exercise. He has a persistent cough and progressive shortness of breath. There are fine crackles at both lung bases on auscultation
Extrinsic allergic alveolitis - hypersensitivity pneumonitis. History of exposure of organic dust with birds. Variety of syndromes it could be: pidgeon breeders lung, bird fanciers lung, budgerigar fanciers disease.
An 82-year-old woman woke up at night acutely short of breath, with a frothy cough and wheeze. She had a myocardial infarction 6 months previously.
Acute left ventricular failure - LVF causes congestion in the pulmonary circulation so the symptoms are respiratory: SOB, cough etc. Oxygen, morphine, diuretics and nitrates should be given.
A 73-year-old man is seen in casualty with acute confusion, fever and vomiting. He had presented to his GP one week earlier with sore throat and cough.
Pneumonia - was not resolved and got worse to cause the old man’s confusion. Patient should have his CURB-65 score calculated.
A 68-year-old ex-smoker on inhalers and long-term oxygen therapy is found to have bilateral peripheral oedema.
COPD - secondary pulmonary hypertension as a result of the patient’s COPD or cor pulmonale gas caused peripheral oedema.
A 22-year-old man is found with CNS and respiratory depression at his bedsit. He has track marks on both upper arms and you see a syringe on the carpet. You notice his pupils are constricted.
Opiate intoxication - signs include CNS depression, miosis, and apnoea. Cocaine would cause dilated pupils. Naloxone is indicated both therapeutically and diagnostically.
48yo man presents with central chest pain on unusual exertion. Resting ECG is normal and there are no obvious risk factor. He would prefer not too take medication until a definitive diagnosis is reached. Most apt initial management?
Exercise ECG
55yo man is taking increasing doses of sublingual GTN for stable angina. He also has cOPD with a reduced PEFR. Coronary angiography shows diffuse disease but he has refused intervention. Most apt initial management?
Calcium Channel Blocker e.g Nifedipine.
1st line for angina = B-blockers (Metoprolol), which is contraindicated in this patient. 2nd line = CCB
60yo man with stable angina is awaiting surgery. He is on the highest tolerated dose of beta blocker and a CCB but is still symptomatic. BP = 170/95. Most apt initial management?
Long acting nitrates e.g Isosorbide mononitrate or transdermal GTN. Nitreate-free periods will be needed to avoid tolerance.
Angina treatment: 1 = B blocker; 2 = CCB; 3 = long acting nitrate.
50yo man present with typical history of exertional angina with ischaemic changes on resting ECG. Coronary angiography shows 70% stenosis of the left anterior descending artery with no significant lesions elsewhere. Most apt initial management?
Angioplasty: those with LMS (left main stem) disease, 3 vessel disease or a reduces EF may benefit from CABG. Most single vessel disease can be adequately managed with PCI.
62yo man, 3 months after an MI, taking aspirin, atenolol and simvastatin, whoso echo shows worsening LV Function. Most apt means of reducing cardiovascular risk?
ACEi therapy - reduces morbidity and mortality associated with LVF, and all patients with LV dysfunction should take it, even if asymptomatic. Caution should be taken if the patient has renal impairment, cardiogenic shock or hypokalaemia.
A 46yo woman, normal BP, cholesterol and blood sugar. BMI = 32. Most apt means of reducing cardiovascular risk?
Weight loss and increased exercise. BMI>30 = obese. Drug therapy can be considered as an adjunct. This is primarily with orlistat which inhibits fat absorption by inhibiting lipases.
77yo man, normal BP, not diabetic, has had 3 episodes of transient left sided weakness in the last month. Most apt means of reducing cardiovascular risk?
Aspirin therapy. Clopidogrel is an alternative in those who do not tolerate aspirin.
54yo man, normal BP, normal lipid profile, BMI=28, random blood glucose = 15mmol/L, fasting blood sugar = 8.5mmol/L. Most apt means of reducing cardiovascular risk?
Weight reduction and metformin therapy. Single random glucose >11.1 and single fasting glucose >7 + symptoms = DM. If asymptomatic, patients need 2 separate elevated readings for a diagnosis.
30yo man attends a routine medical. On examination, a soft ejection systolic murmur is heard at the apex. He has no previous cardiac or resp problems and has a normal pulse and BP.
Innocent murmur
60 yr old Irish woman comes to see you with a progressive one year history of shortness of breath and recent onset of paroxysmal nocturnal dyspnoea. She has been previously well apart from Sydenham’s chorea as a child. She had six normal pregnancies. Examination= plethoric cheeks, pulse is 110 bpm irregular and small volume. BP 128/80mmHg. The JVP is normal. The apex is in the 5th i.c.s. and m.c.l and tapping in nature. The 1st heart sound is loud and P2 accentuated. A low pitched mid-diastolic murmur is heard in the apex
Mitral stenosis - rheumatic. Sydenham’s chorea shows history of rheumatic fever. Almost all cases of mitral stenosis are caused by rheumatic heart disease. The process tends to also cause regurgitation.
MS can have associated malar flush, tapping apex beat and diastolic thrill palpable at the apex.
65yo man had an inferior MI 10 days ago. His initial course was uncomplicated. He suddenly deteriorated with LVF. Pulse is regular 100bpm, normal volume and character. BP = 110.160. Apex beat is dynamic. Low grade3 apical pan-systolic murmur radiating to the axilla.
Mitral Incompetence - TTE is the investigation of choice for diagnosis. Chronic MR is associated with a laterally displaces apex beat with LV dilatation. Mitral valve prolapse is a strong risk factor for development of MR.
33yo woman complains of giddiness on standing and can no longer cross a road on her own as she is worries that she may pass out. She developed diabetes when age 12 and has had treatment to her eyes 2 years ago. Main cause of hypotension?
Autonomic neuropathy - complication of diabetic neuropathy. Fludrocortisone may be helpful in this woman.
50yo man attends A&E with SOB, fever, and hyperdynamic regular pulse of 100. BP = 160/60. He has a murmur at the left sternal edge. he attended a routine dental procedure 2 moths ago.
Infective endocarditis - new murmur + fever should always make you think bacterial endocarditis.
76yo woman was admitted with confusion. She had been increasing unable to care for herself. On admission, she was found to have cool peripheries and her BP = 100/70. Blood results showed plasma urea 25mmol/L and plasma creatinine 120umol.L
Volume depletion - reduction in ECF due to salt and fluid losses which exceed intake. Serum urea and creat will be elevated (N.B. body builders will have naturally high creatinine). IV saline fluid replacement is needed.
A 49-year-old man with a five year history of dyspepsia collapses in the pub. He has noticed that his stools have become black over the last few days.
Choose the SINGLE most likely diagnosis:-
A. Caecal carcinoma B. Meckel's diverticulum C. Anal fissure D. Duodenal ulcer E. Diverticular disease F. Haemorrhoids G. Rectal carcinoma H. Acute ischaemic bowel I. Crohn's disease J. Infective diarrhoea K. Ulcerative colitis
Duodenal ulcer
There is no reason why this cannot be a gastric ulcer but it is not an option on the list. The history of dyspepsia and black tarry stools over the past few days suggests a bleeding peptic ulcer. The dyspepsia is often centred in the upper abdomen and is related to eating. Contrary to popular lay health beliefs there is no good evidence of alcohol as an important risk factor. Key risk factors are NSAID use, H. pylori, smoking and FH of PUD. The most specific and sensitive test is an upper GI endoscopy which will also allow intervention to stop the bleeding ulcer from bleeding. Duodenal ulcers rarely undergo malignant transformation so do not require a compulsory biopsy but gastric ulcers require biopsies to rule this out. Management is aimed at correcting the underlying cause such as discontinuing NSAIDs. H. pylori eradication should be started if the organism is present with triple therapy. Otherwise, a PPI is indicated.
A 65-year-old man with a history of peptic ulceration requires an aortic aneurysm repair electively. Which analgesia is contraindicated? A. Diclofenac B. Epidural bupivacaine C. Codydamol D. Paracetamol E. Morphine
Diclofenac - type of NSAID
A 70-year-old man with atrial fibrillation presents with a two hour history of general abdominal discomfort and is shocked. He has passed bloody diarrhoea.
Choose the SINGLE most likely diagnosis:-
A. Caecal carcinoma B. Meckel's diverticulum C. Anal fissure D. Duodenal ulcer E. Diverticular disease F. Haemorrhoids G. Rectal carcinoma H. Acute ischaemic bowel I. Crohn's disease J. Infective diarrhoea K. Ulcerative colitis
Acute ischaemic bowel
Untreated AF can lead to a thrombus forming inside the heart which can then embolise like this case to the mesenteric vasculature. This person is also old, which is an additional risk due to comorbidities like atherosclerosis. This patient has the symptoms and signs of ischaemic bowel disease (which encompasses acute mesenteric ischaemia, chronic mesenteric ischaemia and colonic ischaemia). This is likely acute mesenteric ischaemia – something that in a person who presents like this, you should maintain a high index of suspicion for as the presentation can be quite non-specific but the condition can be deadly. You would likely in this case opt for surgical intervention without delay although you can cnsider some form of imaging.
22yo man presented with vomiting. He had not been feeling himself for some weeks. On examination, the skin creases of his hands were dark. Blood results showed plasma urea 8.5; Na 121; K 5.1. Main cause of hypotension?
Addison’s disease - low sodium, high potassium, vomiting, and hyperpigmentation all indicate Addison’s.
45yo man presented with severe chest pain radiating down his left arm. He was pale, cold & sweaty. BP=80/50, pulse = 100. Raised JVP and basal creps. Given IV diuretics but getting more SOB. X-ray shows pulmonary congestion. Main cause of hypotension?
Cardiogenic shock - pump dysfunction due to MI, cardiomyopathy, valve dysfunction, or arrhythmias. Raised JVP, basal crackles and pulmonary oedema support cardiac failure. Treatment begins with ABCs, in this case, urgent revascularisation of the coronary arteries is indicated.
67yo man, very drowsy 12h after an aortic aneurysm repair. Had been considerable blood loss and was given 4units of blood during surgery. Had ben written up for pethidine 50-100mg 3 hourly postop and had been given 3 doses. His BP was 150/80 post-op and was now 100/60, pulse = 75. Oxygen saturation was 85%. Main cause of hypotension?
Drug induced. This patient needs ventilation prior to administration of naloxone, titrated to patient response.
80yo man with a history of ischaemic heart disease trips over a paving stone & fractures his hip. An ambulance takes him to A&E. 1 hour after arrival, he develops crushing central chest pain. Most useful investigation?
ECG
19yo male medical student develops acute chest pain during a game of squash. On examination he is distressed there but examination is otherwise unremarkable. There is a family history of sudden death. Most useful investigation?
Transthoracic echo - patient probably has HOCM, symptomatic patients are treated with beta blocker, CCBs or disopyramide. Inheritance is autosomal dominant with a variable penetrance.
55yo obese female complains of 6 month hx of chest pain, radiating to the jaw and both shoulders. Pain is worst at night. ECG and x-rays are normal. Most useful next investigation?
Upper GI endoscopy (best answer out of the options but if trial of PPI was option that would be better) - patients has GORD. Diagnosis is generally clinical and a trial of PPIs, an UGI endoscopy would generally be reserved for complication such as strictures.
30yo alcoholic present with nausea and lower chest pain, radiating around the back. The pain makes the patient curl up in a ball and movement worsens it. On examination there is decreased breath sounds on the left side which is stony dull to percussion at the base. Most useful investigation?
CT scan abdomen - patient has acute pancreatitis. Serum amylase and lipase are also key to diagnosis, but CT is the most sensitive and specific study. Can show enlargement of the pancreas with irregular contours, necrosis, pseudocysts and peripancreatic fat obliteration.
80yo woman on corticosteroids develops acute chest pain while standing up. It is posteriorly sited, radiating anteriorly under the breast. The pain is worse on movement and there is tenderness on the back of the chest. Cardiovascular and respiratory examination are normal. Most useful next investigation?
Thoracic spine x-ray - patient probably has osteoporotic vertebral collapse which is compressing the intercostal nerve and causing her sudden pain in the back of her chest. The hx of corticosteroid use is associated with osteoporosis. For the dx of osteoporosis, a DEXA scan is needed indicating a T score of less than or equal to -2.5
62yo gentleman presents with fatigue, SOB, and anorexia. JVP is elevated, and he has hepatomegaly and swollen ankles.
Congestive cardiac failure - dyspnoea, tiredness, and oedema all point to CCF. Raised JVP, hepatomegaly and peripheral oedema are all signs of RVF. Initial investigations should include ECG, CXR, TTE and bloods (incl. BNP level). First line treatment = ACEi + salt and fluid restriction. Chronic HF patients will also get a B blocker.
55yo man with a hx of systematic HTN present with SOB on exertion and orthopnoea. He has cardiomegaly and laterally displaced apex beat on examination.
Left Ventricular failure - causes congestion in the pulmonary circulation so the symptoms are respiratory.
66yo lady with diabetes, presents with SOB, sweating, nausea and vomiting. She is distressed but has no pain. She is pale, sweaty and grey on inspection.
Silent MI - more common in the elderly and those with DM probably due to autonomic neuropathy.
49yo man presents with a 2week hx of tight central chest pain radiating to the jaw, experienced when he is lying down.
Decubitus angina - usually a complication of HF
45yo man presents with SOB and decreased exercise tolerance. He has a irregular pulse, warm vasodilated peripheries, exophthalmos and a goitre on examination.
Atrial Fibrillation secondary to hyperthyroidism.
Mrs James is a 50 year old diabetic lady who complains of a tightness in her chest plus a cramping sensation in her jaw and neck after climbing 2 flights of stairs to her apartment
Angina
A 45 year old man developed severe central chest pain, lasting for approximately 30 mins. He vomited with the pain, became acutely breathless & sweated profusely.
MI
35yo lady, recently given birth to her 3rd baby. Has 2 weeks hx of fever, malaise, night sweats, lethargy and weight loss. She has left sided weakness, normal BP, microscopic haematuria, a loud pansystolic murmur and bilateral basal crepitations on examination.
Infective endocarditis
20yo man with SOB and chest pain on exertion. Developed palpitation and fainted during a squash game 5 days ago. Examination showed a jerky pulse and a systolic murmur, it was aggravated by lying flat, inspiration, coughing and swallowing.
Hypertrophic obstructive cardiomyopathy.
40 yo man, developed a sharp sternal chest pain 10 day after he has the flu. The pain radiated down the arm to the left shoulder. It was aggravated by lying flat, inspiration, coughing & swallowing. It was relieved by sitting forward.
Pericarditis
45yo Caucasian lady presents with a 4cm chronic ulcer on the medial aspect of the lower leg. She has a history of “bursting” pain in the calf on walking. The skin around the ulcer is brown & heavily indurated. What kind of ulcer is this?
Venous ulcer - occur on a background of deep venous insufficiency. Ulceration usually follows trauma and is usually on the medial gaiter region. The shape is norm irregular with sloping edges. Brown skin around ulcer is due to haemosiderin deposition.
75yo lady with long standing hypertension has had progressive swelling of her legs over the last 3 months. She has consulted her GP because she has developed an ulcer on the anterior aspect of the right shin which weeps serous fluid profusely. She wonders what caused this ulcer?
Cardiac failure - venous ulcer due to RVF
50yo Asian woman, who is known to be diabetic, presents with a painless ulcer on the ball of her foot. She has been complaining of a burning feeling of the soles of her feet for the last year. Type of ulcer?
Neuropathic ulcer - diabetic neuropathy is a microvascular complication of DM and is characterised by a peripheral nerve dysfunction.
70yo man with ischaemic heart disease & COPD, presents with an ulcer between the great & second toes on the right foot. This is associated with pain in the whole foot at night. Type of ulcer?
Arterial ulcer - deep and painful with a well defined edge, usually found on the shin or foot. There may also be local change such as cold peripheries, loss of hair, dusky cyanosis and toenail dystrophy. An angiogram with contrast will define the lesion and determine whether it can be improved by surgical intervention.
30yo woman with long-standing UC, in remission, presents with 2 areas of ulceration on the right mid thigh.
Pyoderma gangrenosum - mainly associated with IBD, RA and the myeloid blood dyscrasias. It causes necrotic tissue leading to deep ulcers, often found on the legs. There are dark red borders.
40yo obese man present with a burning chest pain which is worsened by lying down.
GORD
60yo male smoker complains of severe central chest pain radiating to the left arm. This is post-op following a sigmoidectomy the previous day.
MI - NSTEMI is a common complication of surgical procedures and is often detected as a rise in cardiac markers in the days following surgery.
59yo woman is admitted to A&E with chest pain. The pain is central in origin and came on while she was watching television. The patient has a BMI of 34 and is a known hypertensive. Troponin and CK-MB are not elevated.
Unstable angina
62yo male complains of chest pain at rest. An ECG performed in A&E shows ST elevation. A subsequent angiogram with a provocative agent showed an exaggerated spasm of the coronary arteries.
Variant angina (Prinzmetal’s) - caused by coronary artery vasospasm rather than atherosclerosis (though patient’s will often show some degree of this as well). Occurs at rest and in cycles. ECG will show ST elevation, but only when the patient is having an attack. Cardio biomarkers may be raised as vasospasm can cause damage to the myocardium. Gold standard investigation = coronary angiography and the injection of agents to provoke spasm.
45yo merchant banker is refereed by her GP to the rapid access chest pain clinic. She is asked to perform a treadmill test and complains of chest pan 9 minutes into the test.
Stable angina - during exercise, the ECG will show ST depression. 1st line treatment involves lifestyle changes and antiplatelet therapy.
49yo man with recent history of long-haul travel presents with shortness of breath and haemoptysis. He also complains of chest pain; ECG shows sinus tachycardia.
Pulmonary embolism
53yo lady complains of “crushing” chest pain, sudden onset & spontaneous remission, with no attributable cause. She has no history of hypertension, current BP is 116/76
Anxiety
73yo man presents to A&E with sudden “tearing” chest pain, radiating to the back. The house officer on duty notices unequal arm pulses and BP.
Dissecting aortic aneurysm. Dissecting aneurysms are either type A, which involves the ascending aorta, or type B. Type A dissections require urgent surgery whereas type B can be managed medically if it is not complicated by end organ ischaemia
67yo man recovering from an inferior MI complains of sharp retrosternal chest pain. He comments that leaning forward provides relief of the pain. The attending medical student claims to have heard a “rub” on auscultation.
Pericarditis/Dresslers (if weeks post MI). The classical finding on examination is a friction rub which is said to sound like ‘walking on snow’. There may be diffuse (saddle-shaped) ST elevations on ECG, an effusion on echocardiography and blood results suggesting inflammation. Complications include tamponade and constrictive pericarditis.
There is a harsh pan-systolic murmur loudest at the lower left sternal edge & inaudible at the apex. The apex is not displaced.
Tricuspid regurgitaion
There is a mid-systolic click and a soft late systolic murmur at the apex.
Mitral valve prolapse
The pulse is slow rising. There is an ejection systolic murmur loudest at the right upper sternal border radiating to the carotids
Aortic stenosis
The pulse is irregularly irregular and jerky in character. There is an ejection systolic murmur lessened by squatting loudest at the lower left sternal edge. There is a double apical impulse felt. The apex beat is not displaced.
HOCM - this patient is also in AF which warrants anticoagulation and anti-arrhythmics. Echo must be performed to confirm diagnosis.
There is a constant ‘machinery-like’ murmur throughout systole & diastole.
Patent ductus arteriosus - The ductus arteriosus is a fetal structure which normally closes within 2 days of birth. Persistence can result in heart failure and increased pressures in the pulmonary vasculature as blood is shunted from the aorta into the pulmonary artery. The classic murmur is known as a Gibson murmur or machinery murmur and is best heard in the left infraclavicular area, usually peaking in late systole and continuing into diastole. Maternal rubella infection in the first trimester is a predisposing risk factor for PDA. The definitive diagnostic test is an echocardiogram.
60yo man, recently had an MI, making good progress but has noticed his exercise tolerance is worsening. He is fatigued and has begun to suffer from palpitations. ECG or Echo?
ECG - need to figure out what is causing the palpitations. Could have ectopic beats or paroxysmal AF/Atrial flutter.
Lady with recent hx of MI presents with swelling in her legs which goes all the way up to her thighs. She says she feels depressed and thinks these are side-effects of the medications she is on. You notice that she has pulsation in her neck and her face appears engorged. ECG or Echo?
Echo - elevated JVP and peripheral oedema are signs or RVF. Key investigation is a TTE coupled with Doppler flow studies which allows calculation of the EF.
Urine protein excretion normal range
3.5 gm/24hr over this do a biopsy
Mr H suffered a myocardial infarction 2 days ago. He is now complaining of sharp central chest pain. On direct questioning, he says this is worse when he lies down or moves. ECG or Echo?
ECG - patient has pericarditis, ECG should show a diffuse concave saddle-shaped ST elevation with PR depression (reversed in aVR and V1)
57yo lady, had an MI 6 days ago. Suffering from palpitations and SOB when she lies down. On auscultation there is a prominent third heart sound and a pansystolic murmur. ECG or Echo?
Echo - patient has MR
56 year old male with ankylosing spondylitis. Collapsing pulse was noted on peripheral pulse examination.
Aortic Regurge
65 year old female with a mid-systolic click and a late systolic murmur
Mitral valve prolapse
44 year old diabetic with renal impairment. Fundoscopy revealed AV nipping, silver wiring and small haemorrhages.
Systemic hypertension
34 year old male complaining of headaches, anxiety attacks, recurrent sweating and postural dizziness
Phaeochromocytoma - inherited in MEN2, vHL and NF1. 10% bilateral, 10% malignant, 10% extraadrenal, 25% inherited.
Normal values for haemoglobin
Men-13.5-17.5
Women -12-15.5
23 year old female with a complaint of progressive weight loss, palpitations and frequent loose motions
Hyperthyroidism - in countries where sufficient iodine intake is not an issue, Graves’ disease is the most common cause of hyperthyroidism. Treatment = radioactive iodine, antithyroid medications (eg Carbimazole) or surgery.
66yo man presents with swelling of his right leg to the knee. He had had a right hip replacement 5 weeks previously. Most useful investigation?
Venous Doppler studies - orthopaedic surgery is a strong risk factor for developing a DVT. A low flow in the veins is indicative of a DVT.
A Wells score should be determined in all patients with suspected DV. Score >2 makes condition likely,
18 year old female with progressive weight gain and gradual development of bitemporal hemianopia
Cushings disease - Dexamathasone suppression test can be done to confirm diagnosis.
A 60 year old man who is waiting to have a knee replacement, describes daily episodes of central chest pain when he gets up in the morning. The pain lasts 15 minutes & settles with rest. Most discriminatory investigation?
Coronary angiogram (+ injection agent to provoke spasm) - has variant angina.
A 25 year old PREGNANT woman, who has returned from Australia, developed sudden severe pleuritic pain and mild breathlessness. Her left leg was swollen yesterday, but not today. Most discriminatory investigation?
Ventilation/perfusion scan. She has a PE, would normally do a CTPA but this is contraindicated in pregnancy (and someone with a contrast allergy), so a V/Q scan is the next Ix of choice. A TTE can also be sued to detect RV strain seen with PE.
A 30 year old man has had a 12 hour history of central chest pain, relieved by sitting forwards. He recently had a sore throat. Most discriminatory investigation?
ECG - patient has pericarditis which is best seen on an ECG (diffused saddle shaped ST elevation and PR depression)
64yo lady presents with weight loss, malaise & ankle swelling. Smokes 20/day, has hx of IBD. Pulse = 80, irregularly irregular, BP = 135/85, bilateral oedema and large pelvic mass on exam. Urine = protein +. Most useful investigation?
Pelvic US = mass is likely to be malignant given the patient hx.
Mr A had an MI 2 weeks ago. He now has a fever which comes and goes. He looks pale and feels tired. He experiences chest pain, which is stabbing in nature and worse when he is breathing, sneezing or moving. OE he has reduced expansion on the right hand side and diminished breath sounds over the same area. ECG or Echo?
ECG - patient has Dresslers (post-MI pericarditis). This is believed to be an autoimmune process with myocardial neo-antigens implicated in the aetiology and occurs typically 2-3 weeks post-MI. ECG should show a diffuse concave saddle-shaped ST elevation with PR depression (reversed in aVR and V1). Typical treatment is with aspirin.
73yo man was reviewed in the diabetic clinic. He was complaining of increasing tiredness & loss of appetite. His ankles had become more swollen over the last few weeks. Most useful investigation?
Plasma creatinine - diabetic patients are at risk of diabetic nephropathy and need to have their plasma creatinine regularly checked to monitor renal function. Tiredness, loss of appetite, confusion and pruritis can all be subtle signs of worsening renal function.
54yo Asian woman with TII DM for 15years. Present with ankle swelling. On examination, BP 170/95, JVP not raised & bilateral oedema to the knees. Albumin is low. Most useful investigation?
24h urine protein/spot urine protein-to-creatinine ratio. Patient prob. has nephrotic syndrome, defined by the presence of proteinuria (>3.2g/24h), oedema and hypoalbuminaemia. Some definitions also add hyperlipidaemia.
A gentleman suffers from intermittent episodes of nausea, sweating, central crushing pain, radiating to jaw, lasting a few minutes, which is made worse by exercise. Most diagnostic investigation?
Exercise ECG - patient has stable angina
A 78 year old male with an ejection systolic murmur loudest at the aortic area and radiating to the neck.
Aortic Stenosis
A lady suffers from dyspnoea, coughing up blood as well which is mixed with frothy sputum and is stony dull to percuss. Most diagnostic investigation?
Chest X-ray - patient has pulmonary oedema, probably due to heart failure. An ECG, TTE, and bloods should also done.
A man who works in the city suffers from burning, retrosternal discomfort radiating from epigastrium to jaw & throat. Worse on lying down. Most diagnostic investigation?
Upper GI endoscopy - patient has GORD
An older man collapses with sudden chest pain radiating to back. Most diagnostic investigation?
CT scan - suspected aortic dissection. MRI is more sensitive and specific but it more difficult to obtain acutely.
A 60 year old man on anti-cholinergic drugs presents with supra-pubic pain. He complains that he has not passed any urine in 3 days. O/E he has a distended bladder. most likely diagnosis?
Acute urinary retention his is acute urinary retention caused by anticholinergics. Unwanted effects of this class of drugs include urinary retention, constipation, erectile dysfunction, CNS disturbance, cycloplegia, dry mouth and decreased sweating. Poisoning in severe cases can be treated with anticholinesterases such as physostigmine. This man will need to be catheterised first to relieve the urinary retention and prevent any further complications from occuring.
A 50 year old male smoker describes episodes of dull central chest pain on exertion lasting 10 minutes & relieved by rest. Most discriminatory investigation?
Exercise ECG - patient has stable angina
Serum creatinine
Men - 0.6-1.2 mg/dL
Women- 0.5-1.1 mg/dL
Protein range
6-8.3 mg/dL
Potassium normal range
3.5 - 5 mEq/L
Normal range for direct/conjugated bilirubin
0-0.3 mg/dL
Normal range for total bilirubin
0.3-1.9 mg/dL
Normal range for calcium
2.2-2.6mmol/L
54 year old asymptomatic male. A left paraumbilical bruit was noted on examination
Renal artery stenosis - heard a renal bruit. RAS is due, typically, to atherosclerosis and often presents with hypertension and worsening renal function. A form of imaging is required for diagnosis.
Normal range of sodium
135-145 mEq/L
17 year old male with radiological apperance of rib notching on chest radiograph
Aortic coarctation - characterised by a BP difference between the upper and lower extremities. Posterior rib notching is due to enlargement of collateral vessels due to aortic narrowing. Diagnosis is made on demonstrating narrowing of the aortic arch, typically shown by echocardiography. Treatment may involve surgical repair such as the placement of a stent.
82yo man with HTN for many years. Presents with SOB, worst when lying flat, and peripheral oedema. On examination, JVP is raised, BP=140/60, pulse=120 and is irregularly irregular. Most useful investigation?
Chest X-ray (+ ECG, TTE and bloods, which weren’t options) - patient probably has CCF
30 year old women returning from holiday. Sudden onset chest pain with shortness of breath, coughed blood. She has no other lung disease. Most diagnostic investigation?
CTPA - patient has PE. If contraindicated (pregnant or contrast allergy) a V/Q scan can be done.
